Many patients are unaware of the severe complications that can occur after successful weight loss or what they can do about them

In 2015 there were 196,000 bariatric procedures performed and 50,165 post-bariatric surgeries to deal with side effects or complications from these procedures when patients were actually successful at losing weight. Research shows that only 56% of bariatric surgery patients successfully lose a significant amount of weight (>100 lbs) and keep it off for 5 years. So if we drill down into these numbers, over 45% of patients who successfully lose weight after having gastric bypass, gastric band, or gastric sleeve surgery will need a serious post-bariatric surgery. Yet few patients are ever told this and even fewer are prepared for the mental, physical, emotional and financial impact these secondary surgeries have.

What are the most common post-bariatric complications that require follow up reconstructive surgery?

Outside of severe depression and discomfort resulting from extreme amounts of excess, overhanging skin, patients can also develop the following conditions that ultimately require surgical intervention:

Extreme functional impairments caused by having too much or excessively heavy overhanging skin. Some patients experience a measurable decline in their ability to walk or sit comfortably, resulting in difficulty performing basic life functions.

Musculoskeletal strain from the weight of excess malpositioned adipose tissue.

An infection called intertrigo that occurs within the folds of excess skin and subcutaneous tissue. The infection can be bacterial or fungal and is nearly impossible to cure even with antibiotics and constant attention to cleaning. Why? The weight of the skin folding in on itself causes heat and friction that cannot be avoided. This environment is the perfect breeding ground for infection and cannot be eliminated unless the excess skin is removed.

Cellulitis, which is a bacterial infection typically caused by the staphylococcus, or "staph" bacteria, that seeps into the skin's deepest layers. This means that it is not a superficial rash simply affecting the outer layer of skin, or epidermis. The infection is so extensive it enters into both the dermis and subcutaneous tissue.

Folliculitis, a painful, itchy infection within your hair follicles, which is also typically caused by "staph" bacteria that reproduce exponentially in warm, moist areas.

Panniculitis, which is when an infection causes inflammation of your subcutaneous fat. Post-bariatric patients experiencing panniculitis feel extreme tenderness and pain, typically in their abdomen and buttocks.

Skin ulcers when the valves that keep your vein flowing in one direction to your heart are damaged during bariatric surgery. When your valves are damaged, blood can back up and pool within your veins, or even leak out of your veins into the surrounding tissues. When this happens, the tissue breaks down and an ulcer occurs. These ulcers typically happen in the legs of post-bariatric patients and can result in complete loss of skin, subcutaneous tissue, and even your muscle in extreme cases.

Swollen, red skin abscesses, also caused by a staphylococcus bacterial infection. Abscesses occur within the solid tissue underneath the skin, often along the hair follicle. When infected pus collects within the cavity of a clogged hair follicle, the bacteria can spread rapidly. Abscesses need to be cut open and drained.

Yeast infections in women and fungal dermatitis, or jock itch, in men caused by the fungus tinea. Tinea can be very hard to control in warm, moist environments such as the genitals, inner thighs, and buttocks of post-bariatric patients.

Complete skin necrosis, or skin death, which is intensely painful and is often accompanied with severe fever. Dead skin has to be removed surgically and can be extensive if the necrosis has spread throughout multiple layers of skin and tissue.

A hernia, when the abdominal wall weakens and then opens over time after being damaged during gastric bypass surgery. Weaknesses in the stomach lining, called internal hernias, typically occur after laparoscopic surgeries, and incisional hernias (where a surgical incision doesn't heal properly so stomach membranes push through the incisional hole), are more common with open surgeries.

Inability to maintain adequate hygiene

Uncontrolled, embarrassing body odor

Inability to perform sexual activities

How much weight do you have to lose before experiencing risky complications?

From a clinical perspective, we use the term massive weight loss, or MWL, to describe patients who have lost enough weight to likely experience some of the dangerous side effects or complications listed above. Massive weight loss can be defined as: weight loss of 100 pounds or more, or weight loss equal to or greater than 100% of a person's ideal body weight. MWL and its associated side effects apply to individuals who have lost weight with or without bariatric surgery.

What is post-bariatric surgery called?

Post-bariatric surgeries are typically referred to as body contouring surgeries or skin tightening surgeries. There is another surgery, called a panniculectomy, that refers to a very specific operation to remove folds of skin, called panniculi, from the lower abdomen.

The problem with the gentle names "body contouring" and "skin tightening" is that they are exactly that - too gentle for most patients to immediately understand the complexity and extensive nature of these surgeries. Further, they sound more like aesthetic plastic surgeries and not the medically-necessary reconstructive surgeries that they actually are.

Unfortunately, there isn't much we can do to rename these surgeries, so we spend a lot of time providing education to patients both through this website as well as in our office. Click any of these links to be directed to a specific page with further details on the actual surgeries:

Body Contouring Reconstructive Surgery

Skin Tightening Reconstructive Surgery

Panniculectomy Surgery

What kind of doctor performs post-bariatric corrective surgery?

Doctors trained in plastic and reconstructive surgery perform post-bariatric and post-weight loss body contouring, skin tightening, and panniculectomy surgeries. It is important to note that although plastic and reconstructive surgeons perform these complex surgeries, not all plastic surgeons specialize in or are equipped to handle the complexities of these operations.

For example, Dr. Matt Bindewald specializes in complex reconstructive surgeries. You will notice on our website that he does not perform aesthetic plastic surgery or cosmetic procedures of the face. He specializes only in surgeries of the body. This has allowed him to tailor his entire practice around complex surgeries, most of them reconstructive in nature. He performs his reconstructive surgeries at one hospital - Methodist Specialty and Transplant Hospital in San Antonio, which is a full inpatient hospital with staff specifically trained for these complex cases . Most plastic surgeons operate in outpatient surgical centers that do not have emergency departments and are not equipped to handle complexities that occur during surgery.

Both Dr. Bindewald and his surgical team are highly experienced with extensive 8-12 hour surgeries, as well as with trauma cases. Dr. Bindewald was a general and trauma surgeon in the military before he went back for a 2nd residency in plastic and reconstructive surgery with the specific goal to build a practice around complex reconstructive surgeries. Many physicians seek out Dr. Bindewald for his extensive experience with these cases, and patients often travel to San Antonio for the reassurance of having his skilled hands perform their operation.

What makes post-bariatric and post weight-loss surgeries so complex?

First and foremost, each patients body responds very differently to massive weight loss. Just as we all carry our weight and fat deposits in different parts of our body, so too do we lose it differently. Further, patients who experience weight loss over 100 pounds experience side effects all over their body, not just in one area. Thus, most post-bariatric surgeries require one or more operations that cover multiple areas of the body. Although reconstructive surgeries on the abdomen and lower abdomen (panniculi) are the most common, it is not uncommon for post weight-loss patients to also need or desire surgical intervention on their arms, legs, back and/or buttocks.

Because of the excessive amount of skin and subcutaneous tissue in post weight-loss patients, these surgeries are vastly different from body contouring procedures in patients simply seeking to slim down a body part they consider unsightly. Post weight-loss patients have a deformity that is complex and difficult to treat. Technique and experience can mean the difference between solving a patients problems and making their condition worse. Would closure angles and techniques are awkward but essential to avoid unsightly scars. A patient often has to be turned during surgery from their back to their front - requiring extensive planning in terms of the order in which the surgeon performs the procedures as well as fine-tuned pre-surgical marking and incision/closure planning.

It is typically too risky to divide each of the post-bariatric procedures into their own surgery, so the surgeon needs extensive experience in combining reconstructive procedures to achieve the best possible aesthetic outcome with inconspicuous scars, while minimizing risk, time under anesthesia and blood loss. The best post-bariatric reconstructive surgeons have an acute understanding of skin tension as well as the biomechanics of all of our systems that will ultimately control a patients ability for movement and function. They understand gender-specific contouring requirements, as well as the surgical nuances necessary to best accommodate for differences in age, nutritional status, and ethnicity.

To further complicate matters, patients who previously underwent some form of bariatric surgery typically bear a greater risk during post-bariatric corrective surgeries than patients who lost a large amount of weight without surgery. Why is this? Because bariatric patients lose weight through calorie deficits they often experience long-term problems with malnutrition, often making it much harder for them to recover.

Q&A with Dr. Matt Bindewald

What really happens to your body after massive weight-loss from bariatric surgery?

Although massive weight loss can add precious years to your life, the risks and deformities caused by "successful" weight loss can be alarming. From a strictly clinical perspective, a large number of post-bariatric patients end up with massive, dangerous skin folds. Many people assume this is solely an aesthetic problem, but unfortunately it's not. Further, most bariatric patients spend months or even years planning for their bariatric or gastric bypass surgery, but aren't even aware of the high probability that they will need body contouring procedures afterwards that are likely much more intense than the bariatric procedure.

Extra folds of skin that exist after weight loss collapse inferiorly and inferomedially from the areas where the greatest fat deposits once existed, producing large flank rolls in the upper and mid back, excess skin underneath the arms, and quite often extreme amounts of overhanging pannus, or skin from the lower abdomen that hang over the pubic area into the lower thighs. This causes intense pain, irritation, and often severe infection. In fact, severe deformities are so common after extreme weight loss that there is even a classification system, called the Pittsburgh Rating Scale, that allows us to measure the level of deformity within each patient. Unfortunately, this scale doesn't take into effect the functional disability or hygienic impairment most patients face as well.

Quotes from real bariatric patients

Many bariatric patients aren't told about the medical risks and side effects of weight loss over 100 pounds. These patients share their stories...

"The skin would rub together on my thighs, and I developed bacterial and fungal infections. I would have bandages on me all the time. It was very painful. Just walking was painful. I had hygiene problems." -Barbara B. after losing 150 lbs (Washington Post)

Despite all of her attempts at exacting hygiene, this patient suffered from intense frequent infections and eventually necrosis. She wasn't ever advised before her bariatric surgery of the high likelihood she would need skin removal surgery after her weight loss. "If I hadn't been able to get these (post-bariatric body contouring) surgeries thanks to my parents, I really don't know what I would have done...I think I would regret ever losing the weight in the first place." -Tatiana B. after losing 210 lbs

"As fat women we all had perfect skin," says Cindy. "But there was a lot of skin over all those pounds." (One of her neighbors now refers to her as a "flying squirrel.") - Cindy R. after losing 131 lbs

A year after her surgery, Lee Ann had a tummy tuck because, as she puts it, "When I put on pants, I didn't know where to put the hanging skin." -Lee Ann M. after losing 115 lbs

"Physically, I feel so much better. But the excess skin was utterly depressing. I’d spend hours trying to find clothes to hide my body." -Wendy C. after losing 133 lbs

Contact Us Today

Are you considering pre-planned or emergency surgery to resolve or prevent risks and side effects from excessive skin and tissue after significant weight loss? Dr. Matt Bindewald has extensive experience with these complex reconstructive surgery procedures, and is known for his attention to detail when planning the techniques and tools he will use during your surgery to achieve the best functional and aesthetic outcome given your unique situation.

Dr. Bindewald's exacting techniques and artistry, combined with our transparency in pricing, has resulted in patients who are overwhelmingly pleased with their final outcome as well as their pocketbook.

Contact us online or schedule an appointment in our San Antonio office today. Many out-of-town patients consult with us online first before scheduling their in-person consultation. You can reach us at the phone number or email address listed below, through this web form, or schedule your own appointment via our online request form, which can be accessed here.